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Swinging the Patient Safety Pendulum to Primary Care

Posted By Administration, Friday, February 10, 2017

Patient safety efforts in outpatient settings have been quietly advancing.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


This week, NPSF announced a project we are undertaking in collaboration with CRICO, the Risk Management Foundation of the Harvard Medical Institutions, to identify best practices for managing referrals using electronic health records (EHRs).


Breakdowns in referral management are common and can result in missed or delayed diagnoses and other lapses in patient safety. Closing the loop on referrals is vitally important to achieving correct and timely diagnosis and treatment, and research suggests that EHRs have the potential to close these loops. Through this collaboration, we hope to outline best practices.

I mention this project as an example of how patient safety in outpatient settings has been quietly advancing. As noted in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, we need more research, tools, processes, and structures specifically for ambulatory settings, where most health care is delivered.

Take primary care, for example. A recent review of studies published from 1980 to 2014 finds that patient safety incidents are relatively common in primary care, with roughly 2 to 3 incidents per 100 consultations. Of these, an estimated 4% result in harm, with the most severe cases of harm commonly associated with diagnostic or prescribing errors.

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Although considerable research is still needed into the causes of safety lapses in outpatient settings, we are also beginning to see resources developed that can help health care providers improve. In December, the Agency for Healthcare Research and Quality (AHRQ) began releasing resources as part of the Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. This project is modeled on a similar guide for the hospital setting. Led by MedStar Health Research Institute, the guide for the primary care setting provides resources in four main areas:

  1. Teach-Back: a technique for clearly communicating medical information to patients and families.
  2. Be Prepared to Be Engaged: a toolkit for patients and families to use that helps them get ready for medical encounters.
  3. Medication Management: a toolkit to help engage patients and caregivers in helping maintain accurate medication lists.
  4. Warm Handoff: a practice wherein transfer of care from one clinician to another is done with the participation of the patient and family.

As AHRQ notes, patient engagement has been shown to contribute to improved safety and quality. NPSF has long advocated that patient and family engagement at all levels of the health care system is a vital component of safe care. What works best in a hospital setting can be very different than what works in primary care, however, and the challenges are different. These new materials from AHRQ are a terrific resource for those working in primary care, and they can help frame an incremental approach to improvement.

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Another development comes from the World Health Organization (WHO). I had the privilege of serving as a reviewer last year on the WHO Technical Series on Safer Primary Care. Consisting of nine separate monographs on topics such as patient engagement, human factors, and transitions of care, this series delves into the scope and nature of harm in primary care settings.

Among its goals, the WHO project seeks to raise awareness among health professionals about the potential for safety lapses in primary care and to provide information about how to design and deliver safer care in that setting.

Raising awareness is a necessary first step in any improvement journey. The availability of these new resources is an encouraging sign that the patient safety pendulum is at last swinging to outpatient care.

What are your thoughts about improving the safety of primary care? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

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